Are you able to perform the essential functions/duties of the position for which you are applying, including regular attendance, with or without a reasonable accommodation? (If you need a description of the essential functions of the position for which you are applying, please contact management of the company or ask for a job description)

Employment Accommodation

List reasonable accommodation, which would be necessary to permit you to perform the essential functions of the job

Education Information

Elementary School

Subjects/Courses

Did You Graduate?

List Diploma or Degree

High School

Subjects/Courses

Did You Graduate?

List Diploma or Degree

College

Subjects/Courses

Did You Graduate?

List Diploma or Degree

Trade, Business or Other School

Subjects/Courses

Did You Graduate?

List Diploma or Degree

List any job-related professional or technical organizations to which you belong

Describe any specialized training, apprenticeships, skills or extra curricular activities that are relevant to the job for which you are applying

U.S. Military or Naval Service?

List any job-related skills that you learned while in the U.S. Military or Naval Service

Drivers License #

Drivers License Issuing State

Drivers License Expiration Date

Restriction or Suspensions (respond fully if driving is required by the job for which you are applying)

Former Employers

Starting with last employer first, describe all employment for the last four years.

Name and Address of Company

Start Date

End Date

Type of Business and Phone #:

Start Salary

End Salary

Position

Reason for Leaving

Supervisor's Name

Name and Address of Company

Start Date

End Date

Type of Business and Phone #:

Start Salary

End Salary

Position

Reason for Leaving

Supervisor's Name

Name and Address of Company

Start Date

End Date

Type of Business and Phone #:

Start Salary

End Salary

Position

Reason for Leaving

Supervisor's Name

Name and Address of Company

Start Date

End Date

Type of Business and Phone #:

Start Salary

End Salary

Position

Reason for Leaving

Supervisor's Name

References

Name

Phone

Address

Type of Business

# Years Acquainted

Name

Phone

Address

Type of Business

# Years Acquainted

Name

Phone

Address

Type of Business

# Years Acquainted

Criminal Record

Have you been convicted of a felony within the past 7 years? Conviction will not necessarily disqualify an applicant from employment.

Criminal Selection

If Yes, please explain:

I DECLARE under penalty of perjury that I understand that my falsification, misrepresentation or omission of facts stated in this application or verbally to the Company, will result in immediate dismissal or removal of my application from consideration.

It's ok to contact me about future discounts and events. (Easily unsubscribe at any time.)

Name: Date:

Employment Data Record: Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap, or any other legally protected status. As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply. The purpose for this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the govemment on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Data Records are kept in a Confidential File and are not a part of your Application for Employment or personnel file. Please note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY .EMPLOYMENT DECISION:

Applicant's Statement: I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will'' nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.